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Telehealth: A PrimerWith the emergence of COVID-19, telemedicine has been catapulted into the role of a critically essential service for patients to help mitigate the spread of COVID-19, continue to care for our patients, protect our staff and preserve valuable personal protective equipment. As we rapidly move forward with ambulatory video visits via Vidyo, we recognize the need for continued education and clarification for our providers so they, and their patients, can have the best possible experience and optimize the opportunity for excellent care delivery.1. Telehealth definitionsTelemed Telephone Visit: This is a scheduled telephone conversation. The Visit Type for this visit is TELEMED -Phone Visit [2086].Telehealth Video Visit via Vidyo: This is a scheduled HIPAA-secure, multiple user, two-way synchronous interaction between provider and patient/guardian with video. The Visit Type for this visit is Video Telemed Visit [3859]2. Telemedicine Billing & CodingThis area has been especially dynamic in the COVID-19 era. Restrictions on telephone and video visits have been lifted almost universally by CMS, Medicaid and almost all major payers but there are still payers who have not lifted payment and parity for telemedicine. Because of the changing landscape, please refer to a single source of truth published on the COVID-19 website by Incident Command, with recommendations from RevCycle, Billing, Coding and Compliance, as the situation demands. The document is named Ambulatory Remote Visit Documentation and is linked here: . Trainees and TelemedicineThe ACGME recently clarified the supervision of residents conducting telehealth visits during the pandemic.? Supervision of residents can be either?direct?while being physically present or via concurrent telemedicine technology or?indirect?in which the resident reports to the supervising faculty member after the telemedicine visit.? Implementation and appropriateness of residents engaged in telehealth remain program-level decisions and most importantly “in no situation will a program be penalized retroactively for appropriate engagement of residents and fellows with appropriate supervision in the use of telemedicine during this crisis.” See: ACGME Response To Covid-19: Clarification Regarding Telemedicine?The definition of direct supervision as part of these new telemedicine requirements includes the following classification: “the supervising physician and/or patient is not physically present with the resident and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology.”UW Health’s response to this: 1. Re ACGME’s statement: per UWH Business Integrity, although we can loosen up on supervision to the level ACGME allows, please know that when a licensed independent practitioner is not on the phone or on the video visit with the resident/fellow, that service cannot be billed.? In times such as these, you may need to forego the billing.? We just want you to be aware of the implications. 2. Re direct supervision: First, we believe that the service and supervision is referencing video and not telephone connection.? Second, the faculty physician would need to provide direct supervision during the visit, which as described below would be concurrent monitoring.? This would be similar to the two-way mirror that is specified in the CMS supervision requirements.?3. Re billing: if the faculty physician is only able to observe for 15 minutes of a 30-minute session, they could only bill for the 15 minutes.?Residents/fellows?conducting telephone visits without direct supervision (i.e. indirect) are not billable and should be a MISC NO CHARGE CPT code.?4. Interstate TelemedicineIn response to COVID-19 and because of the President’s declaration of a national emergency, and the HHS Secretary’s declaration of a public health emergency, the HHS Secretary was authorized to waive or modify certain requirements for Medicare, Medicaid, and CHIP programs under Section 1135 of the Social Security Act. The Center for Medicare and Medicaid Services (CMS) will now allow licensed providers to render services outside their state of Medicaid enrollment, among other waivers.?See:?, state law governs whether a non-Federal provider is authorized to provide services in the state without state licensure.?See:??. While the Federation of State Medical Boards (FSMB) is working with states’ Medical Boards to relax these restrictions, it is not universal. As of April 10, 2020, 43 states have granted some kind of waiver allowing a physician who is duly licensed in another state to practice in their state during this crisis.? Some require the healthcare services to be provided free of charge (or other restrictions), others do not.? (See:?)Illinois recently issued guidance permitting out-of-state physicians who are not licensed in Illinois to continue to care for an Illinois patient via telemedicine where there is a “previously established patient/provider relationship.” See: provide care for non-established Illinois patients, the physician may obtain the Illinois COVID-19 Temporary Practice Permit. See: this time, Minnesota has relaxed its restrictions but not completely. Iowa has temporarily waived licensure and all restrictions for telehealth.UW Health’s response to this:In coordination with UW-Madison’s Office of Legal Affairs, what follows provides guidance regarding the practice of medicine for patients who reside outside of Wisconsin:?For purposes of this advice, we are only concerned with a patient’s state of residence, not the state in which they happen to be at the time of an appointment.?In short, for the duration of the COVID-19 national emergency, we believe that it is likely low risk for physicians to continue to care for established patients via telemedicine, even when the patient is located outside of Wisconsin. This is based in part on a risk-balancing assessment and in part on specific exceptions or waivers in the laws.? Because of the ever-shifting landscape and the lack of complete clarity around this issue we cannot guarantee that a physician would not face a licensure action, but we believe that the risk is very low.Of note, as above, the Illinois licensing board expressly clarified that it interprets the Illinois Governor’s recent Executive Orders “to permit an out-of-state health care provider not licensed in Illinois to continue to provide health care services to an Illinois patient via telehealth where there is a previously established provider/patient relationship.”?What constitutes a “previously established provider-patient relationship” is not expressly defined in the Illinois order or licensing board guidance. We think it is generally reasonable, given the COVID-19 emergency and importance of providing safe and appropriate care in patient homes, to take the position that a provider-patient relationship exists if: (1) the patient has previously seen the proposed telemedicine physician or another member of the UW physician’s subspecialty group, or (2) the patient has a UW Health Primary Care Provider (PCP).??It would be harder to argue that outside patients who have scheduled appointments, but no other connection to UW Health, have a provider-patient relationship.? The same goes for brand new patients looking to establish care with any of our providers.? In those cases, whether to proceed will largely depend on the state in which the patient resides.?Please note the SAH patients do not constitute UW Health patients and thus no provider-patient relationship exists.5. Telemedicine ToolsThe United States Department of Health and Human Services recently liberalized HIPAA compliance guidelines for the COVID-19 pandemic. While it is possible now to use a variety of non-public facing video communication tools, many of which are free or low cost, including, Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Doximity, and Skype, UW Health recognizes there are many other regulators who might seek damages in the event of a significant data breach. In addition, when the COVID-19 dust settles and HIPAA fines are back in place, we do not want to then have to pivot to a secure platform. For those reasons, we have two approved, secure and HIPAA-compliant platforms for providers to use, Cisco WebEx for provider-provider and professional videoconferencing and VidyoConnect for provider-patient visits and consults. Because of the need for any new application to undergo the UW Health New Technology Review (NTR) process, in this era of COVID-19 and the need for our personnel and resources to be focused on our response and our patients’ needs, we will not support nor recommend any other platform be used for work and clinical purposes.6. Electronic Prescribing of Controlled Substances (EPCS)If you have not already enrolled in EPCS and may need to prescribe controlled substances, you should sign up online for an appointment with the Medical Staff Administration office at . The MSA office is located at 2639 University Ave, 2nd Floor of the Steinhauer Optical Building on the corner of University and Farley. You must bring the following items with you to enroll:Valid government-issued ID (driver's license, passport, or military ID)Smartphone to enroll and register the Imprivata ID app so that you can prescribe from a location that does not have a fingerprint scannerYou must hold a valid WI DEA or an assignment of the UWHC institutional DEA.7. Keys to a Successful Video (VidyoConnect) VisitDue to the need to rapidly expand our telemedicine capabilities, we have waived the requirements for providers to take the computer-based training modules prior to performing their first real video visits with patients. Nonetheless, we expect UW Health providers to conduct themselves professionally and follow etiquette, develop their own “web-side manner,” and seek out help when needed.Resources on performing a successful video visit exist on line and in the literature but certain universal truths exist:- Be prepared: make sure your technology is ready to go, you know how to mute and unmute your microphone, turn off/on your camera, be fluent with your devices… Having paper and a sharpie to write notes to your patient if their video works but sound doesn’t can be very helpful.- Be self-conscious and self-aware: understand how you might appear, how your voice might sound, or how your body language/positioning might come across to your patient since they can see your body language, your background, and hear your environment. Create a therapeutic telemedicine environment by choosing a place that is quiet, private and with good lighting (but not too bright), a neutral, uncluttered background and keep a professional appearance. Look directly into the camera and, if using a device (smartphone or tablet), make sure it is on a solid surface and not moving around, which can be distracting or even nauseating to the person watching.- Reaffirm the patient has given their consent to perform the visit via video. Explain their options if they have questions or concerns. Other than the phone, the only other option is to be seen in person and this presents significant risk to both them and to the healthcare personnel. Use your best judgment. The risks are minimal (video alone may not meet the standard of care and they need to be seen in person or that the network connection may go down and need to revert to phone) but the benefits are in not having to travel to see you.- Be prepared to coach your patient(s) and colleagues: you may need to remind them to be in a quiet environment, to mute their mic, especially if multiple participants are in the video visit, to move their camera so you can see everyone in the visit, and ensure that they are in a private, secure place. Reassure them that the visit is completely confidential and be sure to introduce anyone else in your room. Finally, reassure them that nothing is being recorded and, if you feel you need to, make sure that they are not recording the visit either---and if they are, be sure that you are comfortable with that. By UWH policy 4.15, the patient does have that right but must disclose that they are recording and it cannot impact uninvolved UWH staff.- Set expectations ahead of time: while the Central Video Visit Schedulers will cover this, you may need to set expectations with patients that you might be running late; that the video may drop if the network signal is weak, that you have a contingency plan (phone) if that happens.- Always strive to meet the standard of care: if the standard of care for a particular problem cannot be met with video, then the patient must be seen by a provider in person (i.e. cardiac or lung exam, abdominal palpation, etc.). While this is challenging in this era, if the situation demands it….Telemedicine is a highly effective means of assessing patients and has extremely high patient and provider satisfaction. While a conventional physical exam cannot be performed, certain elements of an exam can and should be documented (see Appendix for certain exam considerations). It is especially important to document their appearance, more so than you might during an in-office visit---their affect, mood, overall appearance. Finally, in addition to being able to assess your patient, you have an opportunity to view their surroundings, to see their pill bottles or help troubleshoot medical equipment they might be using.Conduct your video visit the way you would an in person visit. After verifying and documenting their consent and understanding of telemedicine, review Health Link for patient information, progress notes, phone visits, etc. Perform and document your visit in Health Link using the “.video” smartphrase at the outset. ................
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